| Autor: |
Gold R; Lead Research Scientist, OCHIN, Portland, Oregon, USA.; Senior Investigator, Kaiser Permanente Center for Health Research, Portland, Oregon, USA., Kaufmann J; Biostatistician, Department of Family Medicine, Oregon Health & Science University, Portland, Oregon, USA., Cottrell EK; Senior Investigator, OCHIN, Portland, Oregon, USA.; Research Associate Professor, Department of Medical Informatics and Clinical Epidemiology, School of Medicine, Oregon Health & Science University, Portland, Oregon, USA., Bunce A; Qualitative Research Scientist, OCHIN, Portland, Oregon, USA., Sheppler CR; Research Associate III, Kaiser Permanente Center for Health Research, Portland, Oregon, USA., Hoopes M; Manager of Research Analytics, OCHIN, Portland, Oregon, USA., Krancari M; Research Associate, OCHIN, Portland, Oregon, USA., Gottlieb LM; Professor of Family and Community Medicine, School of Medicine, University of California San Francisco, San Francisco, California, USA., Bowen M; Practice Coach, OCHIN, Portland, Oregon, USA., Bava J; Trainer, OCHIN, Portland, Oregon, USA., Mossman N; Director of Social and Community Health, OCHIN, Portland, Oregon, USA., Yosuf N; Project Manager III, Fred Hutchinson Cancer Research Center, Seattle, Washington, USA., Marino M; Assistant Professor, Department of Family Medicine, Oregon Health & Science University, Portland, Oregon, USA. |
| Abstrakt: |
Evidence is needed about how to effectively support health care providers in implementing screening for social risks (adverse social determinants of health) and providing related referrals meant to address identified social risks. This need is greatest in underresourced care settings. The authors tested whether an implementation support intervention (6 months of technical assistance and coaching study clinics through a five-step implementation process) improved adoption of social risk activities in community health centers (CHCs). Thirty-one CHC clinics were block-randomized to six wedges that occurred sequentially. Over the 45-month study period from March 2018 to December 2021, data were collected for 6 or more months preintervention , the 6-month intervention period , and 6 or more months postintervention . The authors calculated clinic-level monthly rates of social risk screening results that were entered at in-person encounters and rates of social risk-related referrals. Secondary analyses measured impacts on diabetes-related outcomes. Intervention impact was assessed by comparing clinic performance based on whether they had versus had not yet received the intervention in the preintervention period compared with the intervention and postintervention periods. In assessing the results, the authors note that five clinics withdrew from the study for various bandwidth-related reasons. Of the remaining 26, a total of 19 fully or partially completed all 5 implementation steps, and 7 fully or partially completed at least the first 3 steps. Social risk screening was 2.45 times (95% confidence interval [CI], 1.32-4.39) higher during the intervention period compared with the preintervention period; this impact was not sustained postintervention (rate ratio, 2.16; 95% CI, 0.64-7.27). No significant difference was seen in social risk referral rates during the intervention or postintervention periods. The intervention was associated with greater blood pressure control among patients with diabetes and lower rates of diabetes biomarker screening postintervention. All results must be interpreted considering that the Covid-19 pandemic began midway through the trial, which affected care delivery generally and patients at CHCs particularly. Finally, the study results show that adaptive implementation support was effective at temporarily increasing social risk screening. It is possible that the intervention did not adequately address barriers to sustained implementation or that 6 months was not long enough to cement this change. Underresourced clinics may struggle to participate in support activities over longer periods without adequate resources, even if lengthier support is needed. As policies start requiring documentation of social risk activities, safety-net clinics may be unable to meet these requirements without adequate financial and coaching/technical support. |
